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1.
Clin Interv Aging ; 16: 1265-1274, 2021.
Artigo em Inglês | MEDLINE | ID: mdl-34262266

RESUMO

Purpose: Elderly people represent a growing stroke population with different pathophysiological states than younger. Whether intravenous thrombolysis (IVT) before mechanical thrombectomy (MT) is beneficial for elderly patients remains unclear. This study compared the efficacy and safety between elderly patients treated with MT alone and those treated with both IVT and MT. Patients and Methods: Patients aged ≥65 years who were eligible for IVT within 4.5 h from symptom onset were selected from the ANGEL-ACT (Endovascular Treatment Key Technique and Emergency Work Flow Improvement of Acute Ischemic Stroke) registry, a prospective registry program for patients with endovascular treatment from 111 Chinese stroke centers. The primary efficacy outcome was the 90-day modified Rankin Scale score. We compared efficacy and safety outcomes using ordinal or binary logistic regression or a generalized linear model. Results: In total, 482 elderly patients were included: 187 (38.8%) received IVT and MT (bridging MT) and 295 (61.2%) received MT alone (direct MT). There was no significant difference in the 90-day modified Rankin Scale score between the two groups (median: 4 vs 4 points, respectively; adjusted ß=-0.048, P=0.822). The direct MT group had a shorter onset-to-puncture time (225 vs 255 min, respectively; adjusted ß=-55.074, P=0.002) and a lower rate of parenchymal hemorrhage type 2 within 24 h (2.80% vs 6.63%, respectively; adjusted odds ratio [OR]=0.287, 95% confidence interval [CI]=0.096-0.856, P=0.025). In addition, the direct MT group showed a trend toward a lower incidence of sICH (5.67% vs 10.06%, adjusted OR=0.453, P=0.061), procedure-related complications (7.12% vs 12.30%, adjusted OR=0.499, P=0.052) and distal or new territorial embolization (4.07% vs 6.95%, adjusted OR=0.450, P=0.093). Conclusion: Direct MT had similar efficacy to bridging MT in terms of the 90-day functional outcome in elderly patients, whereas bridging MT had a longer onset-to-puncture time and increased risk of hemorrhagic transformation and procedure-related complications.


Assuntos
Hemorragia Cerebral , Transtornos Cerebrovasculares , AVC Isquêmico , Trombectomia , Administração Intravenosa , Idoso , Hemorragia Cerebral/diagnóstico , Hemorragia Cerebral/etiologia , Transtornos Cerebrovasculares/complicações , Transtornos Cerebrovasculares/diagnóstico , Transtornos Cerebrovasculares/terapia , China/epidemiologia , Estudos de Coortes , Feminino , Humanos , AVC Isquêmico/tratamento farmacológico , AVC Isquêmico/etiologia , AVC Isquêmico/cirurgia , Masculino , Avaliação de Processos e Resultados em Cuidados de Saúde , Melhoria de Qualidade , Trombectomia/efeitos adversos , Trombectomia/métodos , Terapia Trombolítica/métodos , Fluxo de Trabalho
2.
Medicine (Baltimore) ; 100(27): e26454, 2021 Jul 09.
Artigo em Inglês | MEDLINE | ID: mdl-34232178

RESUMO

BACKGROUND: There is no meta-analysis or review in the literature to compare and evaluate the difference and effectiveness of ultrasonic-accelerated thrombolysis (UAT) and catheter directed thrombolysis (CDT) in lower extremity deep vein thrombosis (DVT) patients. Therefore, we conducted this protocol of systematic review and meta-analysis to evaluate the efficacy between UAT and CDT for patients with lower extremity DVT. METHODS: We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocols reporting guidelines to conduct this study. Reviewers will search the PubMed, Cochrane Library, Web of Science, and EMBASE online databases using the key phrases "deep venous thrombosis," "thrombolysis," and "ultrasound-accelerated" for all cohort studies published up to July 22, 2021. There is no restriction in the dates of publication or language in the search for the current review. The primary outcome is major bleeding. Secondary outcomes include health-related quality of life and complications such as recurrent venous thromboembolism, pulmonary embolism, in-stent thrombosis, and death. Review Manager software (v 5.4; Cochrane Collaboration) will be used for the meta-analysis. A P value of < .05 is considered to be statistically significant. RESULTS: We hypothesized that these two methods would provide similar therapeutic benefits. OSF REGISTRATION NUMBER: 10.17605/OSF.IO/YZB3H.


Assuntos
Fibrinolíticos/uso terapêutico , Extremidade Inferior/irrigação sanguínea , Terapia Trombolítica/métodos , Trombose Venosa/tratamento farmacológico , Humanos , Resultado do Tratamento , Ultrassonografia , Trombose Venosa/diagnóstico
3.
Cochrane Database Syst Rev ; 6: CD007574, 2021 06 14.
Artigo em Inglês | MEDLINE | ID: mdl-34125952

RESUMO

BACKGROUND: Most disabling strokes are due to a blockage of a large artery in the brain by a blood clot. Prompt removal of the clot with intra-arterial thrombolytic drugs or mechanical devices, or both, can restore blood flow before major brain damage has occurred, leading to improved recovery. However, these so-called endovascular interventions can cause bleeding in the brain. This is a review of randomised controlled trials of endovascular thrombectomy or intra-arterial thrombolysis, or both, for acute ischaemic stroke. OBJECTIVES: To assess whether endovascular thrombectomy or intra-arterial interventions, or both, plus medical treatment are superior to medical treatment alone in people with acute ischaemic stroke. SEARCH METHODS: We searched the Trials Registers of the Cochrane Stroke Group and Cochrane Vascular Group (last searched 1 September 2020), CENTRAL (the Cochrane Library, 1 September 2020), MEDLINE (May 2010 to 1 September 2020), and Embase (May 2010 to 1 September 2020). We also searched trials registers, screened reference lists, and contacted researchers. SELECTION CRITERIA: Randomised controlled trials (RCTs) of any endovascular intervention plus medical treatment compared with medical treatment alone in people with definite ischaemic stroke. DATA COLLECTION AND ANALYSIS: Two review authors (MBR and MJ) applied the inclusion criteria, extracted data, and assessed trial quality. Two review authors (MBR and HL) assessed risk of bias, and the certainty of the evidence using GRADE. We obtained both published and unpublished data if available. Our primary outcome was favourable functional outcome at the end of the scheduled follow-up period, defined as a modified Rankin Scale score of 0 to 2. Eighteen trials (i.e. all but one included trial) reported their outcome at 90 days. Secondary outcomes were death from all causes at in the acute phase and by the end of follow-up, symptomatic intracranial haemorrhage in the acute phase and by the end of follow-up, neurological status at the end of follow-up, and degree of recanalisation. MAIN RESULTS: We included 19 studies with a total of 3793 participants. The majority of participants had large artery occlusion in the anterior circulation, and were treated within six hours of symptom onset with endovascular thrombectomy. Treatment increased the chance of achieving a good functional outcome, defined as a modified Rankin Scale score of 0 to 2: risk ratio (RR) 1.50 (95% confidence interval (CI) 1.37 to 1.63; 3715 participants, 18 RCTs; high-certainty evidence). Treatment also reduced the risk of death at end of follow-up: RR 0.85 (95% CI 0.75 to 0.97; 3793 participants, 19 RCTs; high-certainty evidence) without increasing the risk of symptomatic intracranial haemorrhage in the acute phase: RR 1.46 (95% CI 0.91 to 2.36; 1559 participants, 6 RCTs; high-certainty evidence) or by end of follow-up: RR 1.05 (95% CI 0.72 to 1.52; 1752 participants, 10 RCTs; high-certainty evidence); however, the wide confidence intervals preclude any firm conclusion. Neurological recovery to National Institutes of Health Stroke Scale (NIHSS) score 0 to 1 and degree of recanalisation rates were better in the treatment group: RR 2.03 (95% CI 1.21 to 3.40; 334 participants, 3 RCTs; high-certainty evidence) and RR 3.11 (95% CI 2.18 to 4.42; 268 participants, 3 RCTs; high-certainty evidence), respectively. AUTHORS' CONCLUSIONS: In individuals with acute ischaemic stroke due to large artery occlusion in the anterior circulation, endovascular thrombectomy can increase the chance of survival with a good functional outcome without increasing the risk of intracerebral haemorrhage or death.


Assuntos
Fibrinolíticos/administração & dosagem , AVC Isquêmico/terapia , Trombólise Mecânica/métodos , Terapia Trombolítica/métodos , Idoso , Viés , Causas de Morte , Feminino , Humanos , Infarto da Artéria Cerebral Média/terapia , Hemorragias Intracranianas/epidemiologia , Hemorragias Intracranianas/etiologia , AVC Isquêmico/tratamento farmacológico , Masculino , Pessoa de Meia-Idade , Ensaios Clínicos Controlados Aleatórios como Assunto , Ativador de Plasminogênio Tipo Uroquinase/administração & dosagem
4.
Medicine (Baltimore) ; 100(25): e26453, 2021 Jun 25.
Artigo em Inglês | MEDLINE | ID: mdl-34160442

RESUMO

BACKGROUND: Recent observations raised concern that the intravenous recombinant tissue plasminogen activator (rt-PA) may result in damage to stroke patients caused by small artery occlusion (SAO). Thus, we perform a protocol for meta-analysis to investigate the efficacy and safety of intravenous thrombolysis with rt-PA in SAO-patients. METHODS: The search-style electronic libraries, including Pubmed, Embase, the Cochrane Library, Web of Science, Wanfang Data, VIP Chinese Journals, and China Biomedical Literature Service System are used for document retrieval in June 2021 with no restrictions on language. The risk of bias in include articles will be assessed using the Cochrane Risk of Bias Tool. We perform the meta-analysis by Stata version 10.0 software and calculated the statistics using the inverse variance statistical method. Binary outcomes are presented as Mantel-Haenszel-style risk ratios with 95% confidence interval. Continuous outcomes are reported as mean differences. RESULTS: The results of the article will be shown in a peer-reviewed journal. CONCLUSION: Intravenous rt-PA may be effective and safe in SAO-patients.


Assuntos
Arteriopatias Oclusivas/tratamento farmacológico , Fibrinolíticos/administração & dosagem , Hemorragias Intracranianas/epidemiologia , Terapia Trombolítica/métodos , AVC Trombótico/tratamento farmacológico , Ativador de Plasminogênio Tecidual/administração & dosagem , Arteriopatias Oclusivas/complicações , Fibrinolíticos/efeitos adversos , Humanos , Injeções Intravenosas , Hemorragias Intracranianas/induzido quimicamente , Metanálise como Assunto , Proteínas Recombinantes/administração & dosagem , Proteínas Recombinantes/efeitos adversos , Revisões Sistemáticas como Assunto , AVC Trombótico/etiologia , Ativador de Plasminogênio Tecidual/efeitos adversos , Resultado do Tratamento
5.
Mayo Clin Proc ; 96(8): 2102-2113, 2021 08.
Artigo em Inglês | MEDLINE | ID: mdl-34144802

RESUMO

OBJECTIVE: To investigate the trend and outcomes of acute pulmonary embolism (PE) during pregnancy and puerperium using a large national database. PATIENTS AND METHODS: The National Inpatient Sample was queried to identify pregnancy-related hospitalizations in the United States from January 1, 2007, through September 30, 2015. Temporal trends in the rates of acute PE and in-hospital mortality rates were extracted. RESULTS: Among 37,524,314 hospitalizations, 6,333 patients (0.02%) had acute PE. The prevalence of comorbidities and risk factors such as hypertension, obesity, and smoking increased, but rates of acute PE did not change significantly (18.01 in 2007 vs 19.36 in 2015, per 100,000 hospitalizations, Ptrends=.21). Advanced therapies were used in a small number of women (systemic thrombolysis: 2.4%, surgical pulmonary embolectomy: 0.5%, and inferior vena cava filter in 8.3%). Rates of in-hospital mortality were almost 200-fold higher among those who had acute PE (29.3 vs 0.13, per 1000 pregnancy-related, P<.001). The rate of in-hospital mortality did not change among women with acute PE (2.6% in 2007 vs 2.5% in 2015, Ptrends=.74). CONCLUSION: In this contemporary analysis of pregnancy-related hospitalizations, acute PE was uncommon, but rates have not decreased over the past decade. Acute PE during pregnancy and puerperium was associated with high maternal mortality, and the rates of in-hospital mortality have not improved. Future studies to improve prevention and management of acute PE during pregnancy and puerperium are warranted.


Assuntos
Hospitalização/estatística & dados numéricos , Complicações Cardiovasculares na Gravidez/epidemiologia , Embolia Pulmonar/epidemiologia , Doença Aguda , Adulto , Feminino , Mortalidade Hospitalar/tendências , Humanos , Incidência , Período Pós-Parto , Gravidez , Complicações Cardiovasculares na Gravidez/terapia , Embolia Pulmonar/terapia , Estudos Retrospectivos , Fatores de Risco , Terapia Trombolítica/métodos , Estados Unidos/epidemiologia , Filtros de Veia Cava , Adulto Jovem
6.
Ann Thorac Surg ; 112(2): 395-404, 2021 08.
Artigo em Inglês | MEDLINE | ID: mdl-33941356

RESUMO

BACKGROUND: Endobronchial ultrasound-guided transbronchial needle injection (EBUS-TBNI) is a novel technique for treating peribronchial targets. The aim of this study was to evaluate preliminary feasibility of thrombolysis of pulmonary emboli via EBUS-TBNI. METHODS: Yorkshire pigs (30-48 kg) were anesthetized and mechanically ventilated. Pre-formed autologous clots were injected sequentially into bilateral lower pulmonary arteries in bilateral models (PE1 and PE2, respectively) or into 1 side in unilateral models using a 21-gauge EBUS-TBNA needle under EBUS guidance. In the bilateral model, 2 hours after clot injection either 25 mL of tissue-plasminogen activator (t-PA; 1mg/mL) or distilled water were administered into each embolus via 25-gauge EBUS-TBNA needle. In the unilateral model, 25 mg t-PA was administered intravenously. Hemodynamic parameters were monitored continuously, and clot dissolved volume was evaluated by EBUS 30 minutes post-treatment administration. RESULTS: All clots (6.1 ± 1.7 mL) were successfully injected as documented by EBUS Doppler imaging. Clot injection in the bilateral model (n = 6) increased pulmonary arterial pressure (mm Hg: Baseline 19.2 ± 5.9 vs PE1: 26.7 ± 9.1, P = .005 vs PE2 29.9 ± 7.1, P = .0007). After t-PA TBNI in the bilateral model (n = 6), pulmonary arterial pressure at 30 minutes post-injection showed improvement (mm Hg: PE2 29.9 ± 7.1 vs post-t-PA 24.4 ± 3.9, P = .0283). Treatment with t-PA TBNI demonstrated superior clot dissolution at 30 minutes post-treatment (dissolved mm3: t-PA TBNI 625.4 ± 156.6 vs t-PA intravenously: 181.6 ± 94.3, P = .0003 vs distilled water TBNI 42.5 ± 33.0, P < .0001). There were no complications. CONCLUSIONS: EBUS-guided transbronchial thrombolysis may be a feasible approach for treating central pulmonary emboli.


Assuntos
Broncoscopia/métodos , Aspiração por Agulha Fina Guiada por Ultrassom Endoscópico/métodos , Endossonografia/métodos , Embolia Pulmonar/terapia , Terapia Trombolítica/métodos , Animais , Modelos Animais de Doenças , Embolia Pulmonar/diagnóstico , Suínos
7.
J Clin Neurosci ; 88: 34-38, 2021 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-33992200

RESUMO

BACKGROUND: APOE ε4 is independently associated with lobar intracranial hemorrhages (ICH). Although the ε4 allele enhances amyloid deposition in blood vessels, the ε2 allele predisposes to vasculopathic changes leading to rupture of amyloid laden vessels. Thus, ε4 and ε2 carriers might have increased susceptibility to ICH. We aimed to study the impact of the apolipoprotein E alleles in the development of symptomatic ICH (sICH). METHODS: We included 384 consecutive ischemic anterior circulation stroke patients submitted to thrombolysis between January 2014 and March 2016. Admission CT-scans were reviewed to calculate the ASPECTS. Patients were followed for up to at least 6 months post-stroke or until death. Outcome was development of sICH, defined according to the ECASS III. RESULTS: Considering APOE genotyping, three patients had ε2/ε2, four had ε2/ε4, 38 had ε2/ε3, 284 had ε3/ε3, 51 had ε3/ε4 and four had ε4/ε4. sICH was associated with sex and diabetes. In multivariate analysis, sICH was not associated with carrying one or more ε4 alleles (OR: 0.483, 95%CI = [0.059, 3.939], p = 0.497) nor with carrying one or more ε2 alleles (OR: 1.369, 95%CI = [0.278, 6.734], p = 0.699). CONCLUSION: No association was found between APOE genotype and the development of symptomatic intracranial hemorrhage.


Assuntos
Apolipoproteínas E/genética , Hemorragia Cerebral/etiologia , AVC Isquêmico/complicações , AVC Isquêmico/tratamento farmacológico , Ativador de Plasminogênio Tecidual/uso terapêutico , Idoso , Feminino , Genótipo , Humanos , Masculino , Pessoa de Meia-Idade , Terapia Trombolítica/métodos
9.
Clin Interv Aging ; 16: 877-886, 2021.
Artigo em Inglês | MEDLINE | ID: mdl-34040364

RESUMO

Background and Purpose: Systemic immune-inflammation index (SII), a novel inflammation index derived from counts of circulating platelets, neutrophils and lymphocytes, has been studied in developing incident cancer. However, the clinical value of SII in acute ischemic stroke (AIS) patients had not been further investigated. Therefore, we aimed to explore the association between SII and severity of stroke as well as 3-month outcome of AIS patients. Methods: A total of 216 AIS patients receiving intravenous thrombolysis (IVT) and 875 healthy controls (HCs) were retrospectively recruited. Blood samples were collected within 24h after admission. Severity of stroke was assessed by the National Institute of Health stroke scale (NIHSS) scores on admission and poor 3-month functional outcome was defined as Modified Rankin Scale (mRS) > 2. Results: SII levels in AIS patients were higher than in HCs. The cut-off value of SII is 545.14×109/L. Patients with SII > 545.14×109/L had higher NIHSS scores (median: 5 vs 9, p < 0.001), a positive correlation between SII and NIHSS was observed (rs = 0.305, p < 0.001). Multivariate logistic regression analyses showed that high SII was one of the independent risk factors for poor prognosis at 3 months of AIS patients (OR = 3.953, 95% CI = 1.702-9.179, p = 0.001). The addition of SII to the conventional prognostic model improved the reclassification (but not discrimination) of the functional outcome (net reclassification index 39.3%, p = 0.007). Conclusion: SII is correlated with stroke severity at admission and can be a novel prognostic biomarker for AIS patients treated with IVT.


Assuntos
Isquemia Encefálica/tratamento farmacológico , AVC Isquêmico/dietoterapia , Terapia Trombolítica/métodos , Ativador de Plasminogênio Tecidual/uso terapêutico , Administração Intravenosa , Idoso , Isquemia Encefálica/sangue , Estudos de Casos e Controles , Humanos , AVC Isquêmico/sangue , Masculino , Pessoa de Meia-Idade , Prognóstico , Estudos Retrospectivos , Fatores de Risco , Resultado do Tratamento
10.
Mayo Clin Proc ; 96(6): 1639-1654, 2021 06.
Artigo em Inglês | MEDLINE | ID: mdl-33952393

RESUMO

Spontaneous intracerebral hemorrhage (ICH) is a medical emergency and is disproportionately associated with higher mortality and long-term disability compared with ischemic stroke. The phrase "time is brain" was derived for patients with large vessel occlusion ischemic stroke in which approximately 1.9 million neurons are lost every minute. Similarly, this statement holds true for ICH patients due to a high volume of neurons that are damaged at initial onset and during hematoma expansion. Most cases of spontaneous ICH pathophysiologically stem from chronic hypertension and rupture of small perforating vessels off of larger cerebral arteries supplying deep brain structures, with cerebral amyloid angiopathy being another cause for lobar hemorrhages in older patients. Optimal ICH medical management strategies include timely diagnosis, aggressive blood pressure control, correction of underlying coagulopathy defects if present, treatment of cerebral edema, and continuous assessment for possible surgical intervention. Current strategies in the surgical management of ICH include newly developed minimally invasive techniques for hematoma evacuation, with the goal of mitigating injury to fiber tracts while accessing the clot. We review evidence-based medical and surgical management of spontaneous ICH with the overall goal of reducing neurologic injury and optimizing functional outcome.


Assuntos
AVC Hemorrágico/diagnóstico , AVC Hemorrágico/mortalidade , AVC Hemorrágico/patologia , AVC Hemorrágico/terapia , Humanos , Terapia Trombolítica/métodos , Resultado do Tratamento
11.
Interv Cardiol Clin ; 10(3): 381-390, 2021 07.
Artigo em Inglês | MEDLINE | ID: mdl-34053624

RESUMO

Fibrinolytic agents provide an important alternative therapeutic strategy in individuals presenting with ST-elevation myocardial infarction (STEMI). Ultimately, primary percutaneous coronary intervention (PCI) is the preferred reperfusion strategy for most patients with STEMI, including elderly patients and patients with coronavirus disease 2019 (COVID-19) infection. Fibrinolytic therapy should always be considered when timely primary PCI cannot be delivered appropriately. Clinicians should promptly recognize the signs of fibrinolytic therapy failure and consider rescue PCI. When fibrinolytics are used, coronary angiography and revascularization should not be conducted within the initial 3 hours after fibrinolytic administration.


Assuntos
Infarto do Miocárdio com Supradesnível do Segmento ST/tratamento farmacológico , Terapia Trombolítica , Fibrinolíticos/uso terapêutico , Humanos , Terapia Trombolítica/métodos
12.
BMC Neurol ; 21(1): 191, 2021 May 11.
Artigo em Inglês | MEDLINE | ID: mdl-33975565

RESUMO

BACKGROUND: The relationship between the neutrophil-to-lymphocyte ratio (NLR) and poor prognostics in acute ischemic stroke (AIS) patients who receive intravenous thrombolysis (IVT) remains controversial. The purpose of this systematic review and meta-analysis was to evaluate the association between the NLR and poor prognosis after IVT. Furthermore, we aimed to determine whether the NLR at admission or post-IVT plays a role in AIS patients who received IVT. METHODS: The PubMed, Embase, Web of Science and China National Knowledge Infrastructure databases were searched for relevant articles until October 7, 2020. Cohort and case-control studies were included if they were related to the NLR in AIS patients treated with IVT. Odds ratios (ORs) and 95 % confidence intervals (95 % CIs) were pooled to estimate the relationship between NLR and poor prognosis after IVT. A random effects model was used to calculate the pooled data. RESULTS: Twelve studies, including 3641 patients, met the predefined inclusion criteria. Higher NLRs were associated with an increased risk of hemorrhagic transformation (HT) (OR = 1.33, 95 % CI = 1.14-1.56, P < 0.001) and a poor 3-month functional outcome (OR = 1.64, 95 % CI = 1.38-1.94, P < 0.001) in AIS patients who received IVT. Subgroup analysis suggested that the NLR at admission rather than post-IVT was associated with a higher risk of HT (OR = 1.33, 95 % CI = 1.01-1.75, P = 0.039). There was no statistically significant difference between higher NLRs and 3-month mortality (OR = 1.14, 95 % CI = 0.97-1.35, P = 0.120). CONCLUSIONS: A high NLR can predict HT and poor 3-month functional outcomes in AIS patients who receive IVT. The NLR at admission rather than the post-IVT NLR was an independent risk factor for an increased risk of HT after IVT.


Assuntos
AVC Isquêmico/sangue , AVC Isquêmico/tratamento farmacológico , Linfócitos , Neutrófilos , Estudos de Casos e Controles , China , Estudos de Coortes , Humanos , Inflamação/sangue , Inflamação/diagnóstico , Contagem de Linfócitos , Prognóstico , Fatores de Risco , Terapia Trombolítica/métodos
13.
Nat Commun ; 12(1): 2590, 2021 05 10.
Artigo em Inglês | MEDLINE | ID: mdl-33972513

RESUMO

Thrombolysis with recombinant tissue plasminogen activator in acute ischemic stroke aims to restore compromised blood flow and prevent further neuronal damage. Despite the proven clinical efficacy of this treatment, little is known about the short-term effects of systemic thrombolysis on structural brain connectivity. In this secondary analysis of the WAKE-UP trial, we used MRI-derived measures of infarct size and estimated structural network disruption to establish that thrombolysis is associated not only with less infarct growth, but also with reduced loss of large-scale connectivity between grey-matter areas after stroke. In a causal mediation analysis, infarct growth mediated a non-significant 8.3% (CI95% [-8.0, 32.6]%) of the clinical effect of thrombolysis on functional outcome. The proportion mediated jointly through infarct growth and change of structural connectivity, especially in the border zone around the infarct core, however, was as high as 33.4% (CI95% [8.8, 77.4]%). Preservation of structural connectivity is thus an important determinant of treatment success and favourable functional outcome in addition to lesion volume. It might, in the future, serve as an imaging endpoint in clinical trials or as a target for therapeutic interventions.


Assuntos
Isquemia Encefálica/tratamento farmacológico , Encéfalo/efeitos dos fármacos , Terapia Trombolítica/métodos , Ativador de Plasminogênio Tecidual/uso terapêutico , Idoso , Encéfalo/diagnóstico por imagem , Encéfalo/patologia , Isquemia Encefálica/diagnóstico por imagem , Isquemia Encefálica/patologia , Progressão da Doença , Fibrinolíticos/uso terapêutico , Humanos , Imageamento por Ressonância Magnética , Pessoa de Meia-Idade , Rede Nervosa/efeitos dos fármacos , Rede Nervosa/patologia , Ensaios Clínicos Controlados Aleatórios como Assunto , Índice de Gravidade de Doença , Acidente Vascular Cerebral/fisiopatologia , Terapia Trombolítica/efeitos adversos , Fatores de Tempo
14.
Am J Emerg Med ; 47: 90-94, 2021 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-33794475

RESUMO

BACKGROUND & PURPOSE: Alteplase is the standard of care for early pharmacologic thrombolysis after acute ischemic stroke (AIS). Alteplase is also considered a high-alert medication and is fraught with potential for error. We sought to describe the difference in medication error rates in in patients receiving alteplase for acute ischemic stroke from regional hospitals compared to patients receiving alteplase at the Comprehensive Stroke Center. METHODS: This was a retrospective cohort comparison of patients who were greater than 18 years old that received intravenous alteplase for the treatment of AIS from June 2015 to June 2018. Several institution specific databases were utilized to obtain pertinent data. A standardized taxonomy was utilized to classify medication errors. Patients were excluded if they received any fibrinolytic other than alteplase or if alteplase was used for a non-stroke indication. Two cohorts (from regional hospitals or the Comprehensive Stroke Center (CSC)) were compared. RESULTS: A total of 676 patients received alteplase during the study period (34% from the CSC and 66% from regional hospitals). There were 133 (19.8%) errors identified. Ten errors (1.6%) occurred at the CSC and 123 (18.2%) errors occurred at regional hospitals. More patients who had an error with alteplase administration (12.7%) experienced a hemorrhagic conversion compared to those with no error in administration (7.2%, p= 0.04). CONCLUSION: The error rate of alteplase infusion for ischemic stroke is high, particularly in patients from referring centers. Errors may be associated with adverse events. Further education and administration safeguards should be implemented to decrease the risk of medication errors.


Assuntos
Fibrinolíticos/administração & dosagem , AVC Isquêmico/tratamento farmacológico , Erros de Medicação/estatística & dados numéricos , Ativador de Plasminogênio Tecidual/administração & dosagem , Administração Intravenosa , Adulto , Idoso , Idoso de 80 Anos ou mais , Bases de Dados Factuais , Feminino , Fibrinolíticos/efeitos adversos , Hospitais Especializados/estatística & dados numéricos , Humanos , AVC Isquêmico/epidemiologia , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Terapia Trombolítica/métodos , Ativador de Plasminogênio Tecidual/efeitos adversos
15.
Postgrad Med ; 133(sup1): 42-50, 2021 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-33863270

RESUMO

Deep venous thrombosis (DVT) is a major cause of acute and chronic morbidity, mortality, and increased healthcare costs. Endovascular methods for thrombus removal and reestablishing venous patency are increasing in both scope and usage. The most commonly used method for endovascular thrombectomy is catheter-directed thrombolysis (CDT). Several studies have shown promise for CDT in alleviating acute symptomatology in acute lower extremity DVT as well as mitigating potential long-term consequences of DVT, such as post-thrombotic syndrome (PTS). The Acute Venous Thrombosis: Thrombus Removal with Adjunctive Catheter-Directed Thrombolysis (ATTRACT) trial is the largest and most comprehensive randomized-controlled trial to date evaluating CDT compared to anticoagulation alone for the treatment of acute symptomatic proximal lower extremity DVT. This review discusses the current status of CDT and adjunctive endovascular interventions for DVT, particularly in the context of the ATTRACT trial.


Assuntos
Procedimentos Endovasculares , Trombólise Mecânica/métodos , Terapia Trombolítica/métodos , Trombose Venosa/terapia , Procedimentos Endovasculares/instrumentação , Procedimentos Endovasculares/métodos , Humanos , Seleção de Pacientes , Ensaios Clínicos Controlados Aleatórios como Assunto , Resultado do Tratamento
16.
Cochrane Database Syst Rev ; 4: CD004437, 2021 04 15.
Artigo em Inglês | MEDLINE | ID: mdl-33857326

RESUMO

BACKGROUND: Thrombolytic therapy is usually reserved for people with clinically serious or massive pulmonary embolism (PE). Evidence suggests that thrombolytic agents may dissolve blood clots more rapidly than heparin and may reduce the death rate associated with PE. However, there are still concerns about the possible risk of adverse effects of thrombolytic therapy, such as major or minor haemorrhage. This is the fourth update of the Cochrane review first published in 2006. OBJECTIVES: To assess the effects of thrombolytic therapy for acute pulmonary embolism. SEARCH METHODS: The Cochrane Vascular Information Specialist searched the Cochrane Vascular Specialised Register, CENTRAL, MEDLINE, Embase, and CINAHL databases and the World Health Organization International Clinical Trials Registry Platform and ClinicalTrials.gov trials registers to 17 August 2020. We undertook reference checking to identify additional studies. SELECTION CRITERIA: We included randomised controlled trials (RCTs) that compared thrombolytic therapy followed by heparin versus heparin alone, heparin plus placebo, or surgical intervention for people with acute PE (massive/submassive). We did not include trials comparing two different thrombolytic agents or different doses of the same thrombolytic drug. DATA COLLECTION AND ANALYSIS: Two review authors (ZZ, QH) assessed the eligibility and risk of bias of trials and extracted data. We calculated effect estimates using the odds ratio (OR) with a 95% confidence interval (CI) or the mean difference (MD) with a 95% CI. The primary outcomes of interest were death, recurrence of PE and haemorrhagic events. We assessed the certainty of the evidence using GRADE criteria. MAIN RESULTS: We identified three new studies for inclusion in this update. We included 21 trials in the review, with a total of 2401 participants. No studies compared thrombolytics versus surgical intervention. We were not able to include one study in the meta-analysis because it provided no extractable data. Most studies carried a high or unclear risk of bias related to randomisation and blinding. Meta-analysis showed that, compared to control (heparin alone or heparin plus placebo), thrombolytics plus heparin probably reduce both the odds of death (OR 0.58, 95% CI 0.38 to 0.88; 19 studies, 2319 participants; low-certainty evidence), and recurrence of PE (OR 0.54, 95% CI 0.32 to 0.91; 12 studies, 2050 participants; low-certainty evidence). Effects on mortality weakened when six studies at high risk of bias were excluded from analysis (OR 0.71, 95% CI 0.45 to 1.13; 13 studies, 2046 participants) and in the analysis of submassive PE participants (OR 0.61, 95% CI 0.37 to 1.02; 1993 participants). Effects on recurrence of PE also weakened after removing one study at high risk of bias for sensitivity analysis (OR 0.60, 95% CI 0.35 to 1.04; 11 studies, 1949 participants). We downgraded the certainty of evidence to low because of 'Risk of bias' concerns. Major haemorrhagic events were probably more common in the thrombolytics group than in the control group (OR 2.84, 95% CI 1.92 to 4.20; 15 studies, 2101 participants; moderate-certainty evidence), as were minor haemorrhagic events (OR 2.97, 95% CI 1.66 to 5.30; 13 studies,1757 participants; low-certainty evidence). We downgraded the certainty of the evidence to moderate or low because of 'Risk of bias' concerns and inconsistency. Haemorrhagic stroke may occur more often in the thrombolytics group than in the control group (OR 7.59, 95% CI 1.38 to 41.72; 2 studies, 1091 participants). Limited data indicated that thrombolytics may benefit haemodynamic outcomes, perfusion lung scanning, pulmonary angiogram assessment, echocardiograms, pulmonary hypertension, coagulation parameters, composite clinical outcomes, need for escalation and survival time to a greater extent than heparin alone. However, the heterogeneity of the studies and the small number of participants involved warrant caution when interpreting results. The length of hospital stay was shorter in the thrombolytics group than in the control group (mean difference (MD) -1.40 days, 95% CI -2.69 to -0.11; 5 studies, 368 participants). Haemodynamic decompensation may occur less in the thrombolytics group than in the control group (OR 0.36, 95% CI 0.20 to 0.66; 3 studies, 1157 participants). Quality of life was similar between the two treatment groups. None of the included studies provided data on post-thrombotic syndrome or on cost comparison. AUTHORS' CONCLUSIONS: Low-certainty evidence suggests that thrombolytics may reduce death following acute pulmonary embolism compared with heparin (the effectiveness was mainly driven by one trial with massive PE). Thrombolytic therapy may be helpful in reducing the recurrence of pulmonary emboli but may cause more major and minor haemorrhagic events, including haemorrhagic stroke. More studies of high methodological quality are needed to assess safety and cost effectiveness of thrombolytic therapy for people with pulmonary embolism.


Assuntos
Fibrinolíticos/uso terapêutico , Heparina/uso terapêutico , Embolia Pulmonar/tratamento farmacológico , Terapia Trombolítica/métodos , Doença Aguda , Viés , Causas de Morte , Fibrinolíticos/efeitos adversos , Hemorragia/induzido quimicamente , Hemorragia/epidemiologia , Heparina/efeitos adversos , Humanos , Embolia Pulmonar/mortalidade , Ensaios Clínicos Controlados Aleatórios como Assunto , Recidiva , Terapia Trombolítica/efeitos adversos
17.
JAMA Netw Open ; 4(4): e217498, 2021 04 01.
Artigo em Inglês | MEDLINE | ID: mdl-33885771

RESUMO

Importance: Acute ischemic stroke (AIS) is a known neurological complication in patients with respiratory symptoms of COVID-19 infection. However, AIS has not been described as a late sequelae in patients without respiratory symptoms of COVID-19. Objective: To assess AIS experienced by adults 50 years or younger in the convalescent phase of asymptomatic COVID-19 infection. Design, Setting, and Participants: This case series prospectively identified consecutive male patients who received care for AIS from public health hospitals in Singapore between May 21, 2020, and October 14, 2020. All of these patients had laboratory-confirmed asymptomatic COVID-19 infection based on a positive SARS-CoV-2 serological (antibodies) test result. These patients were individuals from South Asian countries (India and Bangladesh) who were working in Singapore and living in dormitories. The total number of COVID-19 cases (54 485) in the worker dormitory population was the population at risk. Patients with ongoing respiratory symptoms or positive SARS-CoV-2 serological test results confirmed through reverse transcriptase-polymerase chain reaction nasopharyngeal swabs were excluded. Main Outcomes and Measures: Clinical course, imaging, and laboratory findings were retrieved from the electronic medical records of each participating hospital. The incidence rate of AIS in the case series was compared with that of a historical age-, sex-, and ethnicity-matched national cohort. Results: A total of 18 male patients, with a median (range) age of 41 (35-50) years and South Asian ethnicity, were included. The median (range) time from a positive serological test result to AIS was 54.5 (0-130) days. The median (range) National Institutes of Health Stroke Scale score was 5 (1-25). Ten patients (56%) presented with a large vessel occlusion, of whom 6 patients underwent intravenous thrombolysis and/or endovascular therapy. Only 3 patients (17%) had a possible cardiac source of embolus. The estimated annual incidence rate of AIS was 82.6 cases per 100 000 people in this study compared with 38.2 cases per 100 000 people in the historical age-, sex-, and ethnicity-matched cohort (rate ratio, 2.16; 95% CI, 1.36-3.48; P < .001). Conclusions and Relevance: This case series suggests that the risk for AIS is higher in adults 50 years or younger during the convalescent period of a COVID-19 infection without respiratory symptoms. Acute ischemic stroke could be part of the next wave of complications of COVID-19, and stroke units should be on alert and use serological testing, especially in younger patients or in the absence of traditional risk factors.


Assuntos
Infecções Assintomáticas/epidemiologia , COVID-19 , AVC Isquêmico , SARS-CoV-2 , Trombectomia/métodos , Terapia Trombolítica/métodos , Adulto , COVID-19/complicações , COVID-19/diagnóstico , COVID-19/epidemiologia , Teste Sorológico para COVID-19/métodos , Convalescença , Registros Eletrônicos de Saúde/estatística & dados numéricos , Procedimentos Endovasculares/métodos , Humanos , Incidência , AVC Isquêmico/diagnóstico , AVC Isquêmico/etnologia , AVC Isquêmico/etiologia , Masculino , Pessoa de Meia-Idade , Avaliação de Processos e Resultados em Cuidados de Saúde , Fatores de Risco , SARS-CoV-2/isolamento & purificação , SARS-CoV-2/patogenicidade , Singapura/epidemiologia , Migrantes/estatística & dados numéricos
18.
Medicine (Baltimore) ; 100(15): e25255, 2021 Apr 16.
Artigo em Inglês | MEDLINE | ID: mdl-33847623

RESUMO

RATIONALE: Fibrinolysis shutdown associated with severe thrombotic complications is a recently recognized syndrome that was previously seldom investigated in patients with severe severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. It presents a unique therapeutic dilemma, as anticoagulation with heparin alone is insufficient to address the imbalance in fibrinolysis. And while the use of fibrinolytic agents could limit the disease severity, it is often associated with bleeding complications. There is a need for biomarkers that will guide the timely stratification of patients into those who may benefit from both anticoagulant and fibrinolytic therapies. PATIENT CONCERNS: All 3 patients presented with shortness of breath along with comorbidities predisposing them to severe SARS-CoV-2 infection. One patient (Patient 3) also suffered from bilateral deep venous thrombosis. DIAGNOSES: All 3 patients tested positive for SARS-CoV-2 RNA by reverse transcription polymerase chain reaction (RT-PCR) and were eventually diagnosed with respiratory failure necessitating intubation. INTERVENTIONS: All 3 patients required mechanical ventilation support, 2 of which also required renal replacement therapy. All 3 patients were also placed on anticoagulation therapy. OUTCOMES: In Patients 1 and 2, the initial D-dimer levels of 0.97 µg/ml fibrinogen equivalent units (FEU) and 0.83 µg/ml FEU were only slightly elevated (normal <0.50 µg/ml FEU). They developed rising D-dimer levels to a peak of 13.21 µg/ml FEU and >20.0 µg/ml FEU, respectively, which dropped to 1.34 µg/ml FEU 8 days later in Patient 1 and to 2.94 µg/ml on hospital day 13 in Patient 2. In Patient 3, the D-dimer level on admission was found to be elevated to >20.00 µg/ml FEU together with imaging evidence of thrombosis. And although he received therapeutic heparin infusion, he still developed pulmonary embolism (PE) and his D-dimer level declined to 5.91 µg/ml FEU. Despite "improvement" in their D-dimer levels, all 3 patients succumbed to multi-system organ failure. On postmortem examination, numerous arterial and venous thromboses of varying ages, many consisting primarily of fibrin, were identified in the lungs of all patients. LESSONS: High D-dimer levels, with subsequent downtrend correlating with clinical deterioration, seems to be an indicator of fibrinolysis suppression. These findings can help form a hypothesis, as larger cohorts are necessary to demonstrate their reproducibility.


Assuntos
Anticoagulantes/uso terapêutico , COVID-19 , Produtos de Degradação da Fibrina e do Fibrinogênio/análise , Insuficiência de Múltiplos Órgãos , Terapia Trombolítica/métodos , Autopsia/métodos , COVID-19/sangue , COVID-19/complicações , COVID-19/fisiopatologia , COVID-19/terapia , Deterioração Clínica , Feminino , Fibrinólise , Humanos , Masculino , Pessoa de Meia-Idade , Insuficiência de Múltiplos Órgãos/sangue , Insuficiência de Múltiplos Órgãos/diagnóstico , Insuficiência de Múltiplos Órgãos/etiologia , Valor Preditivo dos Testes , Prognóstico , Terapia de Substituição Renal/métodos , Respiração Artificial/métodos , SARS-CoV-2/isolamento & purificação , Índice de Gravidade de Doença , Trombose Venosa/sangue , Trombose Venosa/complicações , Trombose Venosa/diagnóstico
19.
Medicine (Baltimore) ; 100(15): e25575, 2021 Apr 16.
Artigo em Inglês | MEDLINE | ID: mdl-33847687

RESUMO

RATIONALE: Hereditary protein C deficiency has a high prevalence in Asian populations, being the important risk factor associated with thrombophilia. Traditionally, conservative medication is the first choice for patients with hereditary protein C deficiency. However, there are few reports on whether aggressive surgical treatment can be performed when patients continue to develop life-threatening ischemic symptoms after adequate anticoagulant and thrombolytic therapy. PATIENT CONCERNS: A 40-year-old male presented with right lower extremity pain for 1 week. DIAGNOSIS: Computed tomography angiography (CTA) of lower extremity indicated arterial embolization of the right superficial femoral artery. Vascular ultrasonography showed old extensive thrombus in the deep vein of the left lower extremity. Electrocardiogram reported old anterior myocardial infarction. Sequencing of the gene encoding protein C (PROC) gene revealed that a heterozygous in-frame deletion mutation (c.577-579delAAG, p.192delK). Based on these findings, the diagnosis of hereditary protein C deficiency was made. INTERVENTIONS: The patient was given low-molecular-weight heparin (LMWH) anticoagulation and urokinase treatment immediately. Then we performed the Fogarty catheter embolectomy with about 18.5 cm thrombus being removed and utilized the balloon catheter to dilate the anterior tibial artery. Despite given adequate anticoagulant and thrombolytic therapy postoperatively, the patient still had new thrombosis, and eventually underwent arterial embolectomy and amputation. OUTCOMES: The patient was discharged with good wound healing and continued rivaroxaban treatment at a dose of 20 mg daily. The patient was followed-up monthly until 1 year: there was no adverse ischemic events occurred. LESSONS: Aggressive surgical treatment may be the effective attempt for life-saving when conservative treatment as the first choice had unsatisfactory results in hereditary protein C deficiency patients. The novel oral anticoagulants (NOACs) could be more suitable than warfarin for the treatment and prevention of recurrence in patients with hereditary protein C deficiency.


Assuntos
Embolectomia com Balão/métodos , Deficiência de Proteína C/terapia , Terapia Trombolítica/métodos , Tromboembolia Venosa/terapia , Adulto , Anticoagulantes/administração & dosagem , Heparina de Baixo Peso Molecular/administração & dosagem , Humanos , Masculino , Deficiência de Proteína C/complicações , Resultado do Tratamento , Ativador de Plasminogênio Tipo Uroquinase/administração & dosagem , Tromboembolia Venosa/congênito
20.
Medicine (Baltimore) ; 100(14): e25371, 2021 Apr 09.
Artigo em Inglês | MEDLINE | ID: mdl-33832122

RESUMO

INTRODUCTION: Early acute massive pulmonary thrombosis embolism (PTE) after lung cancer surgery is one of the most fatal surgical complications. It is often accompanied by shock and hypotension, with high mortality rate. Due to surgical wounds, patients with early acute massive PTE after lung cancer surgery have a high risk of thrombolytic bleeding, which renders treatment more challenging and there is currently no standard protocol on how to safely and effectively treat these patients in the clinic. PATIENT CONCERNS: A 66-year-old woman after video-assisted thoracoscopic surgery for lung cancer, experienced sudden severe dyspnea, shock and hypotension with high D-Dimer, changed electrocardiogram (ECG), right ventricular dilatation, severe tricuspid regurgitation, and raised pulmonary arterial pressure on ultrasonic cardiogram (UCG), thromboses found on Ultrasonography of lower extremity vein. DIAGNOSIS: Because of her clinical manifestations and results of bedside auxiliary examinations, the patient was finally diagnosed with acute high-risk PTE after lung cancer surgery. INTERVENTIONS: 1.5 hours after onset of symptoms, thrombolysis using a continuous micropump infusion of 20,000 units/kg urokinase into the peripheral vein for 2 hours was initiated for this patient. OUTCOMES: The patient died of massive hemorrhage after thrombolysis. LESSONS: Treatment for patients with early acute PTE after lung cancer surgery is challenging due to a high risk of thrombolytic bleeding at the surgical site. Real-time monitoring of vital signs during thrombolysis and catheter-directed thrombolysis are recommended for these patients, in order to use the minimum drug dosage for quick curative effects and a low risk of bleeding.


Assuntos
Neoplasias Pulmonares/cirurgia , Embolia Pulmonar/diagnóstico , Terapia Trombolítica/efeitos adversos , Trombose/diagnóstico por imagem , Doença Aguda , Idoso , Evolução Fatal , Feminino , Hemorragia/induzido quimicamente , Humanos , Complicações Pós-Operatórias , Embolia Pulmonar/tratamento farmacológico , Embolia Pulmonar/etiologia , Cirurgia Torácica Vídeoassistida/métodos , Terapia Trombolítica/métodos , Trombose/complicações , Ultrassonografia/métodos , Ativador de Plasminogênio Tipo Uroquinase/administração & dosagem , Ativador de Plasminogênio Tipo Uroquinase/uso terapêutico
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